The first carefully conducted study of brain surgery for epilepsy concludes that the operating table is far more effective than drugs for people whose seizures are not controlled by standard medication a finding that could benefit thousands of patients.
According to the study published in Thursday's New England Journal of Medicine, 15 of 36 patients who had a chunk of their brains removed were free from seizures a year after the operation.
Eight others were free of more critical seizures which previously left them unaware of themselves or their surroundings, said the study's lead author, Dr. Samuel Wiebe of the London Health Sciences Centre in Ontario, Canada.
In the group that received medication, only one patient out of 40 was free of seizures; two others were free of seizures which impaired awareness.
All patients had temporal lobe epilepsy, recurrent seizures caused by brain cells misfiring in the lobe of the brain near the temple. It is the most common form of epilepsy, affecting about half of the 2.3 million U.S. patients, and accounts for about two-thirds of the 1,500 epilepsy operations in the country each year.
Dr. Greg Barkley of the Henry Ford Medical Center in Detroit and a medical adviser to The Epilepsy Foundation called the study superb.
"I think the take-home message this study brings to us is that, yes, if the drugs aren't working, let's consider surgery and not put off the consideration for years and years," he said.
One year is enough to try at least four available drugs and if those do not work, it is probably time to consider surgery, he said.
Dr. Robert Fisher, head of the epilepsy group at Stanford University Medical Center and a past president of the American Epilepsy Society, also called the study important.
Barkley, Fisher and Wiebe all feel that surgery is underused to treat epilepsy. Doctors say tens of thousands of Americans, even 100,000 or more, might benefit, but only about 1,500 operations are done a year, according to a survey made during a 1990 epilepsy conference.
Surgery can leave permanent damage. Up to 4 percent of patients may end up with one side of the body partly paralyzed; about the same percentage may lose short-term verbal memory.
None of the people in the study was paralyzed, but two had memory losses.
The risks may be worth it to people whose seizures make it impossible to get a driver's license and difficult to keep a job or stay in school. Fisher said patients whose epilepsy was cured or greatly improved have asked why they hadn't had the operation decades earlier.
He also said those affected by epilepsy for 20 years may not see as great a benefit from surgery as they could have earlier.
"It's often very difficult to put Humpty Dumpty back together again," he said.
Many doctors see surgery as a last resort because no studies have compared it to medical treatment, Fisher said.
About two dozen drugs, including Valium, Tegritol, phenobarbtal and Neurontin, are used to control epilepsy. They work for most patients, but not for about 400,000 to 600,000 Americans with the disorder.
The reason no comparative study of medicine and surgery has been done is that the operation has been used since the 1930s, before such studies became standard and because the operation works. Doctors also faced an ethical dilemma: How could they refer patients to a medical trial a treatment they considered likely to be less effective when the surgical option was available?
For the study, researchers used patients who were waiting as long as a year for epilepsy surgery. Patients who agreed to be part of the test were divided at random into surgery and medical groups.
Instead of keeping the medical treatment group on drugs longer than usual, the surgery group got moved to the head of the list and had surgery without waiting. Of the 40 people in that group, one decided against surgery, two were found ineligible and one had no seizures during the testing period.
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